Every finding on record at Westwood Nursing and Rehabilitation

Based on facility policy review, medical record review, facility document review, facility investigation review, employee file review, observation, and interview, the facility failed to protect the resident's right to be free from neglect for 1 of 4 (Resident #1) sampled residents reviewed for abuse which resulted in physical harm for Resident #1. The findings include: 1. Review of the undated facility policy titled, Skin and Wound Monitoring and Management, revealed, .A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable .The purpose to this policy is that the facility provides care and services to .Pressure Injury .The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear . Review of the undated facility policy titled, Abuse: Prevention of and Prohibition Against, revealed, .Abuse is willful infliction of injury .with resulting physical harm, pain, or mental anguish. This includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Adverse event is an untoward, undesirable, and usually unanticipated event that causes .serious injury, or the risk thereof .Identification .Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor of the Facility administrator immediately .the deprivation by an individual of goods and services .Reporting/Response .Allegations of abuse, neglect .will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included Parkinson's Disease with Dyskinesia, Morbid Obesity, Type 2 Diabetes Mellitus, and Urinary Tract Infection. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #1 required partial/moderate assistance with toileting hygiene, supervision or touching assistance with roll left and right, and substantial/maximal assistance with toilet transfer and chair/bed-to-chair transfer. Resident #1 had no skin conditions coded on the quarterly MDS. Review of the Progress Notes dated 5/17/2025, revealed .SN [skilled nurse] called to resident room by CNA [Certified Nursing Assistant], stated resident was not acting right, will not arouse. SN checked BS [blood sugar], sugar @58 [milligrams/deciliter (mg/dl)]. 1 mg [milligram] of Glucagon administered to left thigh. Resident did not arouse, pupils unresponsive to light. Resident still would not arouse, repeating same incoherent words. BS rechecked, sugar 52 [mg/dl]. Resident displayed severe jerking, unable to get resident to arouse. [Named Facility Nurse Practitioner (FNP)] notified, received order to send resident to the ER [emergency room ] .EMS [Emergency Medical Services] arrived. Residents BS 71 at the time. She was more alert at that time, but c/o [complained of] severe back and kidney pain. Resident has been transported to the hospital . Review of the Progress Notes dated 5/17/2025, revealed .This nurse called [named Hospital #1] ED [Emergency Department] for an update on resident. Talked to .ED and then was transferred to med-surg floor and .informed that resident was admitted to hospital on med-surg floor for UTI [Urinary Tract Infection] and Hypoglycemia .patient POA [Power of Attorney], informed at this time . Review of Hospital #1's Wound Location report dated 5/17/2025, revealed .Site A Location [left] upper buttock .abrasion .looks like skin peeled off from removal of bandage .Site B Location [right] upper buttock .abrasion looks like skin peeled off from removal of bandage .Site C Location [left] under gluteal cleft [crease between the buttocks and leg] .abrasion .Site D Location [right] under gluteal cleft .abrasion . Review of the Evening Shift CNA ASSIGNMENT SHEET dated 5/17/2025 revealed CNA F was assigned 7 rooms on the 200 Hall. The census reflected 11 residents to be on CNA F's assignment for this date. The assignment sheet noted, .SN [Skilled Nurse] found resident [Resident #1] on a bedpan that no CNA said they put her on it. Resident's bottom was open in a ring due to sitting on bed pan - the bed was wet, brown ringed & [and] cover over resident was wet. [Named CNA F] denied putting the resident on the bedpan . The assignment sheet was signed by Registered Nurse (RN) A. Review of the Care Plan Report for Resident #1 dated 5/17/2025, revealed a focus for at risk for impaired skin integrity, abrasions, bruises, skin tears due to fragile skin and on 5/17/2025 an intervention was added which revealed, .Skin Injury - Staff educated to not leave resident on bed pan for extended periods of time and remain with resident during use to reduce the risk of injury . Review of the Progress Notes dated 5/18/2025 revealed, . [Named Family Member (FM A)] is resident's POA and 1st emergency contact and was updated on profile sheet. FM A wanted to make sure that staff notified her with all healthcare needs, and she was the one to make decisions when [Named Resident #1] unable to make wishes known .She visits often, but has no right to make healthcare decisions. [Named FM A] and I discussed [Named Resident #1]'s overall physical and mental decline .Daughter realistic in mom's status, stated she had noted the decline, with decrease alertness, periods of confusion, and forgetfulness noted. Discussed with daughter, that this past Saturday, [Named Resident #1] was noted lethargic, blood sugar low, prepared to transfer to ER [Emergency Room] . Review of the Progress Notes dated 5/20/2025 revealed, .continuation of previous note [referring to the Progress Notes dated 5/18/2025]: When preparing resident to be transferred to ER, resident was on the bedpan, noted excoriated buttock with skin reddened, raw and opened areas noted. [Named Resident #1] had fell asleep while on bedpan, staff performed peri care, charge nurse documented skin change, and performed wound care. CN [Charge Nurse] educated staff on change in resident's cognition, to make sure to monitor closely, limit use of bedpan, due to the risk for skin integrity. Daughter made aware .Will update care plan and educate staff . Review of the facility investigation signed by the Administrator and Staffing Coordinator on 5/19/2025 revealed, On the evening of 5/17/2025, this writer received a call from [Named Staffing Coordinator]/On Call Nurse, that resident [Named Resident #1] had a decline and was needing transportation to the hospital. The staff had discovered that [Resident #1] was on the bed pan when they were preparing her for transfer to the hospital. Staff was concerned about length of time [Resident #1] had been on the bed pan as their [there] was a skin sheared area to [Resident #1]'s buttock. We began to investigate by getting statements from prior night shift and day shift that had care for [Resident #1]. [Resident #1] is normally cognitive enough that she calls for staff when she if [is] finished with bed pan but had a change of condition during the day which did not allow her to call for assistance as normal. Nurses were called to the room at supper time due [to] CNA calling them to the room because of a report of change of condition. Nurses assessed, consulted with [Named Facility Nurse Practitioner] to send to ER. Upon getting resident ready for transport staff discovered the bed pan under resident. Nurses noted sheared area to buttocks. Resident was transported to [Named Hospital #1] for evaluation and treatment of change of condition .An in service was initiated on 5/17/2025 regarding bed pan usage. Staff member [CNA F] that was assigned to [Resident #1] refused to sign in service leaving facility stating that she would not be returning. Staff Coordinator contacted employee to discuss with employee stating that she was not signing the in service nor writing a statement. Employee also stated that she would not be returning to facility. Review of CNA F's employee file revealed a termination form was noted with last day worked 5/17/2025, with explanation for termination as employee quit without notice and employee is not eligible for rehire. The termination form was signed by the Administrator and the Director of Nursing (DON) on 5/20/2025. Review of the Progress Notes dated 5/22/2025, revealed .Resident returned to facility from acute Hospital stay related to UTI, hypoglycemia. Resident noted to have large scattered bruising/discoloration to buttocks measuring 31x25 [Centimeters]. New order received for Hydrocolloid dressings to be placed on buttocks. Resident is alert, slight confusion noted at times today . Review of the LN (Licensed Nurse)-Skin Ulcer Non-Pressure Weekly note dated 5/23/2025, revealed .Site: Buttock .Shear-redness noted with open area noted to central portion .Size .31 [cm long] x 25 [cm wide] .Depth 0.1[cm] .New order for hydrocolloid [ a type of bandage that helps wounds heal by creating a moist environment and absorbing fluid] to buttocks . Review of the Order Review History Report revealed, .TX [treatment] Buttock-Cleanse with NS [Normal Saline] or wound cleanser. Apply hydrocolloid dressing every day shift .Order Date .5/23/2025 . Observation of wound care in Resident #1's room on 5/28/2025 at 10:35 AM, revealed right hip with a defined sheared area in the shape of a crescent (a curved shape) which measured approximately 32 cm long, 2.5 cm in the widest area, and superficial depth. The wound to the right hip extended from the top of her buttocks to right above her leg. A wound was noted in the center above her buttocks fold measuring approximately 4.5 cm long, widest area of 1 cm, and superficial in depth. The left buttocks revealed a sheared area in the shape of a crescent at the top of buttocks approximately 8 cm long, 2 cm wide, and superficial in depth. Further down on the left buttocks revealed another crescent shaped wound at the base of the buttocks approximately 4 cm long, 2 cm wide, and superficial in depth. On the upper top of her lower leg under the fold of the left buttocks appeared another crescent shaped wound measuring approximately 3 cm long, 2 cm wide, and superficial in depth. During an interview on 5/27/2025 at 9:15 AM, Resident #1 stated, .I went to the hospital because my sugar went low .staff left me on the bed pan, I couldn't find my call light, I waited and waited .I fell asleep on the bedpan .It was over 3 hours . Resident #1 was asked how she knew it was over 3 hours. Resident #1 pointed at her watch on her arm and stated, I wear a watch and watch the time . Resident #1 was observed in a wide bariatric bed with an alternating pressure mattress. Resident #1 stated, .the facility got me this bed when I got back from the hospital . During an interview on 5/27/2025 at 11:07 AM, RN A stated, .I was the nurse that sent [Named Resident #1] to the hospital .she slept most of the day .sugar was low I gave glucagon it was still at 52 [mg/dl] I called the ambulance .I told the CNA let's get her cleaned up before EMS gets her .she was on a bedpan when we took her off the bedpan it took the hide off her skin .the CNA caring for her was a new aide here .I know she knew she had the resident because I made the assignments that day .there was urine in the bedpan .no CNA claimed to have put her on the bedpan .the resident can't put herself on the bedpan .the CNA assigned to her walked out . RN A was asked to explain Resident #1's condition when she found her on the bedpan. RN A stated, .I found dark urine in the bed pan, brown ring on her bed .I could tell she hadn't been changed she told me her bottom was sore .the resident was unable to tell us who put her on the bedpan .I called [Named Family Member FM E] she was the first person to call on the list but I think that has been changed now . During an interview on 5/27/2025 at 11:37 AM, FM B stated, .I spoke with the Director of Nursing [DON] and Administrator .we had mutual talk about the change in her cognition and being left on the bedpan for a long time .I don't have details on the time she was left on the bedpan .usually she could tell the staff when she was ready to be off the bedpan but her cognition had changed . During an interview on 5/27/2025 at 1:45 PM, CNA C was asked to give examples of neglect. CNA C stated, .if a CNA neglects to check on a resident, leave them wet, not answering call lights .if you place a resident on a bedpan you should come back and check to make sure the resident is off the bedpan .the in service was to not leave them on the bedpan because [Named Resident #1] was left on the bedpan to long . During an interview on 5/27/2025 at 1:50 PM, CNA D was asked the different examples of abuse and why CNAs were given education on placing a resident on bedpan in May. CNA D stated, .it should be reported immediately to the Abuse Coordinator the Administrator .we were in serviced on the bedpan because [Named Resident #1] was left on the bedpan too long .we were trained to come back after 5-10 minutes, take the resident off the bedpan clean the resident up because if the resident is left to long it could leave sores and mess up the residents skin . During an interview on 5/28/2025 at 2:08 PM, the Staffing Coordinator was asked about CNA F's employment, work performance, and why the employee no longer works at the facility. The Staffing Coordinator stated, .I would not expect the resident to be left on the bedpan for a long period of time, I wish things had been different .residents should be checked on at least every 2 hours .I have no idea on what time she was placed on the bedpan because the employee failed to fill out a statement .generally one person could place her on the bedpan .she couldn't put herself on the bedpan . The Staffing Coordinator was asked to review the Evening Shift CNA ASSIGNMENT SHEET dated 5/17/2025. The Staffing Coordinator stated, .it doesn't appear that she [Resident #1] received the care she needed. The Staffing Coordinator was asked if she (Resident #1) didn't receive the care she needed would that be considered neglect. The Staffing Coordinator stated, .I guess so .I will say she is usually someone who could tell you she needs off the bed pan, but a CNA should return and check on the resident or report to the oncoming shift they are on the bed pan. I do feel the wounds occurred due to the bedpan . During a telephone interview on 5/28/2025 at 2:10 PM, the FNP stated, .I haven't seen the wounds yet, I am going by tomorrow to look at it. [RN A] told me what she assumed happened. I was aware the facility performed an investigation .staff assigned to her that day isn't employed anymore . The FNP was asked what she would expect a CNA to do after placing a resident on a bedpan. FNP stated, .place the resident on the bed pan .provide privacy .return to take the resident off the bedpan no longer that 15-30 minutes or stay with the resident until finished .the CNA should know to go back and check on the resident . During an interview on 5/28/2025 at 2:20 PM, the DON was asked about the incident involving Resident #1. The DON stated, .the resident was always very verbal and would call and anyone would take her off the bedpan, not always the same person getting her off as the one who put her on the bedpan . The DON was asked if a resident was unable to express her needs, are their needs just not performed. The DON stated, .they [staff member] should have come back .It [wounds] appeared to show the definition of a bedpan .the CNA no longer works here .we immediately started education with the staff .I don't know what time she was placed on the bedpan but I know it was on day shift .the employee left that night .the assignment sheet just shows the resident needed to be changed . The DON was asked if Resident #1 was given goods and services she needed on 5/17/2025 on the evening shift. The DON stated, .personal care is taking someone off the bedpan . The DON was asked if Resident #1 experienced neglect on 5/17/2025. The DON stated, .neglect is willfully done .the resident was sent to the ER because she was in a different situation that [than] she normally was .blood sugar was low, nurse tried to fix that .the area to the bottom was discovered and the nurse immediately reacted to that .the staff was trained to not always assume the resident can tell you when they are finished but always follow back with the resident . During an interview on 5/28/2025 at 2:41 PM, the Administrator was asked if she was the Abuse Coordinator and did the facility feel Resident #1 experienced abuse related to neglect on 5/17/2025. The Administrator stated, .I am the Abuse Coordinator .if the resident was able to tell me .I wouldn't call that neglect .but in talking with staff she was coherent when she was placed on the bedpan .I don't know what time she was placed on the bedpan .[Named CNA F] would not give a witness statement .she just walked out .abuse is willfully done with the intent to harm someone . The Administrator was asked to review the facility policy on abuse and neglect and stated, .withholding services .it does state that but in this instance, we provided the services in the thoughts she could communicate with us .I would expect a CNA to follow up but generally she is very cognitive .I feel like she had a change in condition . The Administrator was asked if a resident can't communicate their needs can a staff member just leave their needs unmet. The Administrator stated, .No ma'am . The Administrator was asked did the resident receive the services she needed on 5/17/2025. The Administrator stated, .I think the staff did that .the CNA seen the condition change and a nurse was called in to check the resident .after looking at everything and statement of the change in the condition with the resident .we cared for the resident as normally we would, and we got her medical attention .it was no intentional act on my staff's part . The Administrator was asked why CNA F left without filling out a witness statement on 5/17/2025 and never returned to work. The Administrator stated, .I am not sure why she left .I never seen anything that was abusive or neglectful .We did talk to [Named FM A] the POA .she didn't get along with [Named FM E ] they butt heads a lot .we didn't want to be caught in a crossfire, so we made sure the POA was the first person to call . During a telephone interview on 5/28/2025 at 4:35 PM, RN G from Hospital #1 stated, .I remember [Named Resident #1]. I try to be diligent about looking at the resident skin when they are admitted to the hospital .when I rolled the resident over she had horizonal abrasions on both sides above her buttocks and also under her gluteal folds .one on each side .the areas were not noted on the paperwork from the facility .it looked like someone had removed a bandage and ripped the top layer of her skin off .it did look like a bedpan could have caused the areas .the resident didn't voice how the areas happened .

Based on facility policy review, medical record review, hospital record review, and facility investigation review, the facility failed to ensure allegations of neglect were reported immediately, but not later than 2 hours after the allegation was made for 1 of 4 (Resident #1) sampled residents reviewed for abuse. The findings include: 1. Review of the undated facility policy titled, Skin and Wound Monitoring and Management, revealed, .A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable .The purpose to this policy is that the facility provides care and services to .Pressure Injury .The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear . Review of the undated facility policy titled, Abuse: Prevention of and Prohibition Against, revealed, .Abuse is willful infliction of injury .with resulting physical harm, pain, or mental anguish. This includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Adverse event is an untoward, undesirable, and usually unanticipated event that causes .serious injury, or the risk thereof .Identification .Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor of the Facility administrator immediately .the deprivation by an individual of goods and services .Reporting/Response .Allegations of abuse, neglect .will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included Parkinson's Disease with Dyskinesia, Morbid Obesity, Type 2 Diabetes Mellitus, and Urinary Tract Infection. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Resident #1 required partial/moderate assistance with toileting hygiene, supervision or touching assistance with roll left and right, and substantial/maximal assistance with toilet transfer and chair/bed-to-chair transfer. Resident #1 had no skin conditions coded on the quarterly MDS. Review of the Progress Notes dated 5/17/2025, Resident #1 was not acting right and was unarousable. Her blood sugar (BS) was 58 milligrams/deciliter (mg/dl) and Glucagon was administered. Resident #1 remained unresponsive and displayed severe jerking. The provider was notified, and Resident #1 was sent to the Emergency Room. Her BS was 71 at the time of transfer, and she was more alert and complained of severe back and kidney pain. Review of the Progress Notes dated 5/17/2025 revealed, .This nurse called [named Hospital #1] ED [Emergency Department] for an update on resident. Talked to .ED and then was transferred to med-surg floor and .informed that resident was admitted to hospital on med-surg floor for UTI and Hypoglycemia .patient POA [Power of Attorney], informed at this time . Review of Hospital #1's Wound Location report dated 5/17/2025 revealed .Site A Location [left] upper buttock .abrasion .looks like skin peeled off from removal of bandage .Site B Location [right] upper buttock .abrasion looks like skin peeled off from removal of bandage .Site C Location [left] under gluteal cleft [crease between the buttocks and leg] .abrasion .Site D Location [right] under gluteal cleft .abrasion . Review of the Evening Shift CNA ASSIGNMENT SHEET dated 5/17/2025, revealed CNA F was assigned to Resident #1. The assignment sheet noted the nurse found Resident #1 on a bedpan and her bottom was open in a ring. The bed was, .wet, brown ringed & the cover over resident was wet . CNA F denied placing Resident #1 on the bedpan. The assignment sheet was signed by Registered (RN) A. Review of the Progress Notes dated 5/18/2025 revealed, .[Named Family Member FM A] is resident's POA and 1st emergency contact and was updated on profile sheet. Daughter wanted to make sure that staff notified her with all healthcare needs, and she was the one to make decisions when [Named Resident #1] unable to make wishes known .[Named Complainant]. She visits often, but has no right to make healthcare decisions. [Named FM A] and I discussed [Named Resident #1]'s overall physical and mental decline . stated she had noted the decline, with decrease alertness, periods of confusion, and forgetfulness noted. Discussed with daughter, that this past Saturday, [Named Resident #1] was noted lethargic, blood sugar low, prepared to transfer to ER [Emergency Room] . Review of the Care Plan Report dated 5/17/2025, revealed the intervention was added which documented, .Skin Injury-Staff educated to not leave resident on bed pan for extended periods of time and remain with resident during use to reduce the risk of injury . Review of the facility investigation signed by the Administrator and Staffing Coordinator on 5/19/2025 revealed, On the evening of 5/17/2025, this writer received a call from [Named Staffing Coordinator]/On Call Nurse, that resident [Named Resident #1] had a decline and was needing transportation to the hospital. The staff had discovered that [Resident #1] was on the bed pan when they were preparing her for transfer to the hospital. Staff was concerned about length of time [Resident #1] had been on the bed pan as their [there] was a skin sheared area to [Resident #1]'s buttock. We began to investigate by getting statements from prior night shift and day shift that had care for [Resident #1]. [Resident #1] is normally cognitive enough that she calls for staff when she if [is] finished with bed pan but had a change of condition during the day which did not allow her to call for assistance as normal. Nurses were called to the room at supper time due [to] CNA calling them to the room because of a report of change of condition. Nurses assessed, consulted with [Named Facility Nurse Practitioner] to send to ER. Upon getting resident ready for transport staff discovered the bed pan under resident. Nurses noted sheared [[NAME]] area to buttocks. Resident was transported to [Named Hospital #1] for evaluation and treatment of change of condition .An in service was initiated on 5/17/2025 regarding bed pan usage. Staff member [CNA F] that was assigned to [Resident #1] refused to sign in service leaving facility stating that she would not be returning. Staff Coordinator contacted employee to discuss with employee stating that she was not signing the in service nor writing a statement. Employee also stated that she would not be returning to facility. Review of the Progress Notes dated 5/20/2025 revealed, .continuation of previous note [referring to the Progress Notes dated 5/18/2025]: When preparing resident to be transferred to ER, resident was on the bedpan, noted excoriated buttock with skin reddened, raw and opened areas noted. [Named Resident #1] had fell asleep while on bedpan, staff performed peri care, charge nurse documented skin change, and performed wound care. CN [Charge Nurse] educated staff on change in resident's cognition, to make sure to monitor closely, limit use of bedpan, due to the risk for skin integrity .Will update care plan and educate staff . Review of the Progress Notes dated 5/22/2025 revealed Resident #1 returned to the facility from the hospital and was noted to have a large scattering of bruising and discoloration to the buttocks which measured 31 centimeters (cm) by 25 cm. Resident #1 was noted to exhibit slight confusion at times. Review of the CNA F's employee file revealed a termination form was noted with last day worked 5/17/2025 with explanation for termination as employee quit without notice and employee is not eligible for rehire. The termination form signed by the Administrator and DON on 5/20/2025. During an interview on 5/27/2025 at 9:15 AM, Resident #1 stated, .staff left me on . bed pan, I couldn't find my call light, I waited and waited .I fell asleep on the bedpan .It was over 3 hours . Resident #1 was asked how she knew it was over 3 hours. Resident #1 pointed at her watch on her arm and stated, I wear a watch and watch the time . Resident #1 was observed in a wide bariatric bed with an alternating pressure mattress. Resident #1 stated,the facility got me this bed when I got back from the hospital . During an interview on 5/27/2025 at 11:07 AM, RN A stated, .I was the nurse that sent [Named Resident #1] to the hospital .she slept most of the day .sugar was low I gave glucagon it was still at 52 I called the ambulance .I told the CNA let's get her cleaned up before EMS gets her .she was on a bedpan when we took her off the bedpan it took the hide off her skin .the CNA caring for her was a new aide here .I know she knew she had the resident because I made the assignments that day .there was urine in the bedpan .no CNA claimed to have put her on the bedpan .the resident can't put herself on the bedpan .the CNA assigned to her walked out . RN A was asked to explain Resident #1's condition when she found her on the bedpan. RN A stated, .I found dark urine in the bed pan, brown ring on her bed .I could tell she hadn't been changed she told me her bottom was sore .the resident was unable to tell us who put her on the bedpan .I called [Named Family Member FM E Complainant] she was the first person to call on the list but I think that has been changed now . During an interview on 5/27/2025 at 11:37 AM, FM B stated, .I spoke with the Director of Nursing [DON] and Administrator .we had mutual talk about the change in her cognition and being left on the bedpan for a long time .I don't have details on the time she was left on the bedpan .usually she could tell the staff when she was ready to be off the bedpan but her cognition had changed . Refer to F-600

Based on policy review, observation, and interview, the facility failed to ensure food was stored and prepared under sanitary conditions when 1 of 2 ice machines were observed to have multiple black spots, when the container of sugar was out of date, and when wet nesting of dishware was observed. The facility had a census of 52, with all residents receiving a meal tray from the kitchen. The findings include: 1. Review of the facility policy titled, General Sanitation and Cleaning, dated 1/2025, revealed .Cleaning Instructions: Ice Machine and Equipment .Ice machine and equipment .will be cleaned and sanitized on a regular basis . Review of the facility policy titled, Food Storage, dated 8/2019, revealed .Foods shall be labeled, dated, and covered. Dates used may be a date prepared/opened and/or use-by date . Review of the facility policy titled, Cleaning Dishes/Dish Machine, dated 1/2021, revealed .Air dry. Use drying racks if needed; do not stack dishes immediately after washing .inspect for cleanliness and dryness, and put them away . 2. Observation in the kitchen on 5/12/2024 at 8:45 AM and 2:04 PM, revealed multiple black dots to the left, right and upper inside wall of the ice machine. During an interview on 5/14/2025 at 2:20 PM, the Certified Dietary Manager (CDM) confirmed the ice machine should have been clean. 3. During observation and interview in the kitchen on 5/12/2024 at 8:45 AM and 2:04 PM, with the CDM present, revealed sugar inside the sugar bin dated, use by 5/2/2024. The CDM confirmed the sugar inside the sugar bin should have a current use by date. 4. During observation and interview in the kitchen on 5/12/2024 at 2:04 PM, with the CDM present, revealed standing water droplets on the following: a. 4 of 6 small steam pans stacked on top of each other. b. 3 of 6 small steam pans stacked on top of each other. c. 4 of 5 medium steam pans stacked on top of each other. d. 3 of 4 large steam pans stacked on top of each other. The CDM confirmed that pans should be air dried prior to stacking.

Based on policy review, medical record review, and interview, the facility failed to follow interventions to prevent falls for 1 of 4 residents (Resident #21) reviewed for falls. The findings include: 1. Review of the facility policy titled, Fall Management System, dated 1/2025, revealed .It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs . 2. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including Hemiplegia (paralysis of the muscles of the lower face, arm, and leg on one side of the body) and Hemiparesis (weakness or the inability to move on one side of the body) following Cerebral Infarction (stroke), Dementia, Anxiety, Alzheimer's Disease, Unsteadiness on feet, Fracture of Left Femur, and Osteoporosis. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed short and long term memory problems, severely impaired decision-making skills, physical behaviors occurred on 1 to 3 days of assessment period, wandering occurred daily, and required assistance with Activities of Daily Living (ADLs). Review of the Physician's Order dated 4/10/2025, revealed Check functioning DAILY, check proper functioning and placement of mat [weighted based alarm mat] every shift . Review of the facility's Occurrence Investigation Interview Report dated 4/15/2025 at 3:30 PM, revealed .laying on the floor on left side of body .What was the Resident doing the last time you saw them before the occurrence .Sitting in wheelchair lobby .Does the Resident have an alarm .YES .alarm was not on the chair .The root cause of the occurrence is .resident leaning forward in wheelchair . Review of the Nurse Note dated 4/15/2025 at 4:21 PM, revealed Resident pressure alarm was not on her wheelchair at the time of incident. Review of the Nurse Note dated 4/15/2025 at 6:42 PM, revealed [Daughter] notified of unwitnessed fall w [with] / no injuries . Review of the Care Plan dated 4/25/2025, revealed .At Risk for Falls .Interventions on 4/4/2025 .Weight based alarm mat to be in place r/t [related to] impulsive behaviors to reduce risk of falls . During an interview on 5/13/2025 at 4:23 PM, Licensed Practical Nurse (LPN) D confirmed that she was working at the time of Resident #21's fall. LPN D reviewed the fall documentation from 4/15/2025 and confirmed that it was her documentation and Resident #21 did not have a weight-based alarm mat on the chair when the fall occurred. LPN D was asked should the alarm have been in place at the time of the fall. LPN D stated, Yes. During an observation and interview on 5/14/2025 at 9:44 AM, Certified Nursing Assistant (CNA) E demonstrated the use of a weight-based alarm mat in a chair. CNA E was asked to place the weighted based alarm mat in a chair in the position she would have placed it for Resident #21. CNA E confirmed Resident #21 sat directly on top of the alarm mat. A surveyor sat on the alarm mat and leaned forward causing the alarm to sound. CNA E confirmed the alarm would have sounded when Resident #21 leaned forward. During an interview on 5/14/2025 at 11:44 AM, the Director of Nursing (DON) confirmed residents should have fall prevention devices in place as ordered.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed during medication administration when 2 of 3 nurses (Registered Nurse (RN) B and RN C) did not perform proper hand hygiene while administering medications for 2 of 4 (Resident #3 and #306) residents. The findings include: 1. Review of the facility policy titled, Hand Hygiene, dated 1/2025, revealed .Hand hygiene is one of the most effective measures to prevent the spread of infection .after contact with objects .in the immediate vicinity of the resident .after removing and disposing of personal protective equipment .Vigorously lather hands with soap and rub them together .for a minimum of 20 seconds .dry hand thoroughly with paper towels and then turn off faucets with a clean, dry paper towel . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Diabetes, and Chronic Kidney Disease. Observation during medication administration on 5/14/2025 at 8:38 AM, in Resident #3's room revealed RN B completed administration of oral medications to Resident #3, then immediately administered eye drops to both eyes without changing gloves or performing hand hygiene. During an interview on 5/15/2025 at 3:00 PM, the Director of Nurses (DON) was asked should a nurse complete oral medication administration and immediately move to administering eye drops without hand hygiene. The DON stated, No . they should remove their gloves and perform hand hygiene, then apply another pair of gloves . 4. Review of the medical record revealed Resident #306 was admitted to the facility on [DATE], with diagnoses including Infection and Inflammatory Reaction due to Cardiac and Vascular Devices, Implants, and Grafts, Acute Respiratory Failure, and Pyelonephritis. Observation during medication administration on 5/14/2025 at 3:45 PM, in Resident #306's room revealed RN C performed hand hygiene and turned off the faucet with her wet hand. During an interview on 5/15/2025 at 3:00 PM, the DON was asked should staff perform hand hygiene and use their hand to turn off the faucet. The DON stated, .No they are supposed to turn it off with a clean paper towel .

Based on policy review, facility investigation review, weather website review, medical record review, and interview, the facility failed to ensure a safe environment with adequate supervision to prevent elopement for 1 of 3 sampled residents (Resident #1) reviewed for elopement/wandering behaviors. The facility's failure to ensure residents were adequately supervised resulted in Immediate Jeopardy when Resident #1, who had severe cognitive impairment, exited the facility unsupervised and was found walking on the side of a 2-lane road by passersby. The resident was unsupervised and out of the facility for approximately 25 minutes. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), Regional Nurse Manager, and the Regional Director of Operation were notified of the Immediate Jeopardy (IJ) for F-689 on 12/19/2022 at 4:07 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and a severity of J, which is Substandard Quality of Care. The IJ existed from 9/20/2022 through 9/26/2022. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyor on 12/19/2022. The facility was cited for past noncompliance for F-689 and is not required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled, Elopements and Wandering Patients, with a revision date of 6/21/2022, revealed, .facility ensures that residents .are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care .Elopement .occurs when a resident leaves the premises or a safe area without authorization . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Dementia, Peripheral Vascular Disease, Hypotension, History of Falls and Unsteadiness on Feet. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had severe cognitive impairment and required limited assistance with walking. Review of the Care Plan dated 9/19/2022 revealed, .has exhibited Wandering Behavior .Use wander guard . Review of the nurses' note dated 9/20/2022 at 21:30 [9:30 PM], written by Licensed Practical Nurse (LPN) #1 revealed, .Resident managed to get outside unassisted, unbenounsed [unbeknownst] to staff. After a thorough & [and] extensive search of the facility & grounds. Head to toe assessment performed after assisting resident back inside the facility .Administrator notified of resident fleeing from facility. One on one care provided for the remainder of the shift .Pt [patient] is cooperative & [and] no longer exit seeking at this moment. Wander guard intact & working properly . Review of Timeanddate.com website revealed the outside temperature on 9/20/2022 at 7:53 PM was 75 degrees Fahrenheit. During an interview on 12/16/2022 at 8:17 AM, LPN #1 was asked about the elopement incident on 9/20/2022. LPN #1 stated, .I was told in report .that [Resident #1] had exhibited some exit seeking behaviors and had put a wander guard on him .that night [Resident #1] was ok .the next night when we came in .I noticed the CNAs [Certified Nursing Assistants] were having trouble with [Resident #1] .[Resident #1] had his belongs [belongings] packed up with him in the wash basin .he was convinced it was coming a storm .she took him down to his room .got him snack .convinced him the best thing is for him to stay here .we thought he was good .she went back to check on him and he was gone .she came out and immediate said that he was missing .looked at room to room .started going outside .had flashlights .a nurse stayed inside .I was outside .we were looking .down the driveway .when I came back inside .I answered the phone .[person on the phone] said there is a little man down here at the end of the driveway .with his rollator .they just happened to be driving and saw him .it was definitely God .I took off on foot .they were on the right .on the side of the road . LPN #1 confirmed the door alarm did not sound and stated, .there is a board at the nurses station and it didn't light up or nothing . During an interview 12/16/2022 at 2:02 PM, CNA #1 was asked about the elopement incident on 9/20/2022. CNA #1 stated, We had just clocked in .[Resident #1] was already wanting to leave .it was the very first time we have dealt with him like that .while passing snack he wasn't there .I immediately ran to the nurses desk .told them thought he had escaped .we were looking everywhere .a couple found him in [on] the highway . During an interview on 12/19/2022 at 6:45 AM CNA #2 stated, .we thought [Resident #1] had went to his room .when we got to his room we noticed he wasn't there .we started looking .we figured something was up .we looked everywhere the whole facility .then we went outside .then one of the nurse got a call .and said they had him at the end of the drive .he had his walker with him .it scared us .he wasn't gone long . During a telephone interview on 12/19/2022 at 2:29 PM Registered Nurse (RN) #1 stated, .it was my first night .I'm surprised he made it to the driveway .he had told them earlier before my shift he was going home .he has his clothes packed .had everything in his walker .I think I took the call .it was a .boy .they pulled up .we checked him and made sure he didn't fall down the hill . During an interview on 12/19/2022 at 3:25 PM, the Administrator was asked about the elopement. The Administrator stated, .when they notified me [Resident #1] was already back in the building .we reviewed the camera footage .walked around the building .couldn't understand the door because every time I opened it .it alarmed .still confused about the door .the staff reported to me there was no sound .when he opened it .[named business] .arrived and he said there was an issue with the key pad .they fixed the key pad .and the door has worked ever since . The facility's corrective action plan was verified by the surveyor on 12/19/2022 through medical record review, observations, staff interviews, in-service logs, and review of audits. 1. On 9/20/2022 at 7:41 PM, Resident #1 was assisted back into the facility. Resident #1 was not present at the facility during the investigation. 2. On 9/20/2022 Resident #1 was assessed by LPN #1 with no injuries. This was verified by the surveyor by interview with LPN #1. 3. On 9/20/2022 a 100 percent (%) bed count was conducted to ensure all residents were accounted for. This was verified by the surveyor by conducting staff interviews. 4. On 9/20/2022 Resident #1's elopement risk assessment was revised by the Director of Nursing (DON). This was verified by the surveyor through review of the elopement risk assessment. 5. On 9/20/2022 Resident #1's Care Plan was revised to include an intervention for elopement risk. This was verified by the surveyor through review of the Care Plan. 6. On 9/20/2022 the Responsible Party was notified of event. This was verified by the surveyor though medical record review. 7. On 9/20/2022 the Administrator interviewed Resident #1, and the resident was found to have no psychological harm resulting from the event. This was verified by the surveyor through interviews. 8. On 9/21/2022 the 200 Hall exit door was assessed by the Director of Maintenance and found to have a delay in the door closing. The door was monitored until the door was repaired on 9/22/2022. This was verified by the surveyor through staff interviews and review of the door company invoice for repairs. 9. On 9/20/2022, hourly door checks for all exit doors were initiated and Resident #1 was placed on 1:1 beginning on 9/20/2022 at 9:00 PM, until 9/21/2022 at 3:45 PM. This was verified by the surveyor through review of documented hourly door check logs beginning on 9/20/2022 at 8:00 PM through 9/22/2022 at 5:00 PM and staff interviews. 10. On 9/22/2022 elopement risk assessments were completed and updated on 100% of residents. All new admissions had elopement risk assessments completed. This was verified by the surveyor through medical records reviews for other random residents. 11. On 9/21/2022 a policy review was conducted. The Regional Director of Operations and the Regional Nurse Manager educated the facility Administration and Nurse Managers on patient safety through monitoring elopement risks and concerns. This was verified by the surveyor through review of the in-service sheet. 12. Beginning on 9/20/2022 elopement drills were completed on day and night shifts through 9/27/2022. Education was provided after each drill. Elopement drills were conducted daily for 7 days, then weekly for 3 weeks and monthly for 2 months. This was verified by the surveyor through staff interviews and review of the completed elopement drills log. 13. On 9/21/2022 staff received in-service training and on 9/22/2022 an online training was assigned to staff through Relias related to Elopement Risks and Understanding Wandering and Elopement with a due date of 9/26/2022. Newly hired personnel will be educated during orientation on elopement and wandering patient policy with diversion tips list and the magnetic alarm door malfunction procedure beginning on 9/22/2022. The training was verified by the surveyor through review of all active staff sign-in sheets for in-services and staff interviews on all shifts. 14. On 9/21/2022 the Interdisciplinary Team (IDT) met with the Medical Director and conducted a Quality Assurance and Performance Improvement (QAPI) review to discuss incident and interventions put in place and preventative measures. This was verified by the surveyor through review of the QAPI meeting minutes. 15. On 9/21/2022 audits of the exit doors and alarms, new hire education, new admission and quarterly elopement risk assessment, and care plans were initiated on 9/21/2022 and continue daily. QA [Quality Assurance] audits for compliance were conducted every shift daily x [times] 7 days, weekly x 3 weeks, monthly x 2 months, and quarterly ongoing with any adverse findings reported to the QAPI committee. This was verified by the surveyor through review of the audits and interview with the Administrator.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained by 2 of 3 (Licensed Practical Nurse (LPN) #1 and 5) nurses observed during dressing change, 2 of 11 (Certified Nursing Assistant (CNA) #3 and 5) and 2 of 4 (LPN #3 and Registered Nurse (RN) #1) nurses failed to perform hand hygiene during dining observation and medication administration. The findings included: 1. The facility's .Hand Hygiene . policy documented, .Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers .Dry thoroughly with a single-use towel .Use clean/dry towel to turn off the faucet . The facility's .Skin Assessment . policy with a revision date of 11/17 documented, .Dispose of contaminated items in the appropriate containers . 2. The (MONTH) (YEAR) physician's orders [REDACTED].[MEDICATION NAME] Packing Strip 1 (inch) x (times) 5 yard bandage .one time daily .clean wound with NS (Normal Saline) pat dry, irrigate wound with (Named wound cleanser) and pack undermined area with [MEDICATION NAME] packing strips, cover with dressing daily . 3. Observation in Resident #36's room on 5/8/18 at 1:45 PM during wound care, revealed LPN #5 donned gloves with a split on the left finger and continued the wound dressing change. Interview with the Assistant Director of Nursing (ADON) on 5/9/18 at 9:50 AM, in the conference room, the ADON was asked if a nurse donned and realized one of the fingers was split, what should the nurse do. The ADON stated, Stop and take off the gloves and wash hands. 4. Observation in Resident #39's room on 5/9/18 at 10:55 AM, revealed LPN #1 performed a dressing change on Resident #39's legs. LPN #1 double gloved and placed the 4 x 4's on the overbed table with the resident's hydration mug and 2 empty orange juice containers without cleaning the table or applying a barrier. LPN #1 then dipped half of the 4 x 4s in normal saline that was already poured in an emesis basin on the table and proceeded to clean Resident #39's left lower leg using the same 4 X 4 to clean the bloody areas of the wound. She then blotted the left lower leg dry with a clean dry 4 x 4s, repeatedly blotting over the same areas with the same 4 x 4. LPN #1 removed scissors from her uniform pocket and cut the silver alginate into blocks and placed the medicine on the open areas of the left leg without disinfecting the scissors. LPN #1 then applied the boot to the resident's left leg. LPN #1 removed one set of gloves and covered the boot with an elastic [MEDICATION NAME] and then removed the second set of gloves. LPN #1 again double gloved without performing hand hygiene and placed 4 x 4s into the same normal saline solution used to clean Resident #39's left leg. LPN #1 cleaned the right lower leg with the normal saline soaked 4 x 4s going over the same bloody areas. LPN #1 blotted the right lower leg dry with dry 4 x 4s, cut (named packing) with scissors that were on the bed and applied the (named packing) to the left leg open areas and did not pack the wound. LPN #1 applied the boot to Resident #39's right leg, removed one set of gloves, wrapped the right lower leg with elastic [MEDICATION NAME] and removed her gloves. LPN #1 again double gloved, reached in her uniform pocket for a tongue depressor and mixed (named) ointment with (named) powder in a medicine cup. LPN #1 failed to wash her hands prior to donning the gloves and failed to disinfect the scissors. LPN #1 then applied the mixture of medicine to the right foot and toes with the tongue depressor and massaged the medicine between the toes with her fingers. With these same scissors LPN #1 cut a piece of gauze to go between Resident #39 toes, laid the scissors on the bed, and wrapped the toes on Resident #39's right foot with gauze. Without changing gloves LPN #1 used the same tongue depressor to mix (named) ointment and (named) powder in a medicine cup, applied the medication to Resident #39's left foot and toes, massaged the medicine between the toes, covered the toes with a non stick pad and wrapped the left foot and toes with [MEDICATION NAME]. LPN #1 removed her gloves and placed the scissors back into her pocket and left the emesis basin on a chair that was beside the bed. Interview with the Director of Nursing (DON) on 5/9/18 at 1:28 PM in the conference room, the DON was asked if she expected staff to use a barrier for supplies during treatments. The DON stated, Yes ma'am. The DON was asked if it was appropriate to use the bedside table and scissors without disinfecting them. The DON stated, No, ma'am, and nothing else should be on the table . The DON was asked if she expected the staff to use the same normal saline to clean more than one wound, mix and apply medication for two different wounds with the same tongue depressor and the DON stated, No. 5. Observation in the dining room on 5/7/18 beginning at 11:25 AM, revealed CNA #3 touched the inside of the bowls, resident's chair, resident's straw and picked up the silverware without performing hand hygiene. Observation in the dining room on 5/7/18 beginning at 11:25 AM, revealed CNA #5 rubbed her uniform and placed her thumb inside the dinner plate and inside the dessert bowl and then touched a resident with her hand while she served trays without performing hand hygiene. Interview with the Administrator on 5/9/18 at 2:39 PM in the Administrator's office, the Administrator was asked if it was appropriate for staff to place their thumbs inside plates and bowls, touch their uniforms, and then assist residents during dining without performing hand hygiene and the Administrator stated, No .Their hands should be washed if they touch anything . 6. Observations in Resident #32's room on 5/8/18 at 7:44 AM, 7:47 AM, and 8:04 AM, during medication administration revealed LPN #3 performed hand hygiene and turned the faucet off with her bare hand. Observations in Resident #21's room on 5/8/18 at 8:12 AM, 8:14 AM, and 8:16 AM, during medication administration revealed LPN #3 performed hand hygiene and turned the faucet off with her bare hand. Observations in Resident #106's room on 5/8/18 at 11:27 AM, 11:29 AM, 11:32 AM and 11:40 AM, during medication administration revealed LPN #3 performed hand hygiene and turned the faucet off with the same wet paper towel. 7. Observation in Resident #4's room on 5/8/18 at 8:34 AM, during medication administration revealed RN #1 performed hand hygiene and turned the faucet off with the same wet paper towel that she had used to dry her hands. Observation in Resident #45's room on 5/8/18 at 9:55 AM, 9:57 AM and 10:00 AM, during medication administration revealed RN #1 performed hand hygiene and turned the faucet off with the same wet paper towel. Interview with the DON on 5/8/18 at 12:15 PM in the DON's office, the DON was asked if it was acceptable when performing hand hygiene to turn the faucet off with bare hands or the same wet paper towel used to dry their hands and the DON stated, No ma'am .

Based on policy review, medical record review, observation, and interview, the facility failed to follow physician orders [REDACTED].#36) sampled residents reviewed with pressure ulcers. The findings included: 1. The facility's .Documentation of Wound Treatments policy with a revision date of 11/17 documented, .The purpose of this guidance is to provide a consistent process for accurate and complete wound treatment . 2. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a stage 3 pressure ulcer with a length of 4 centimeters (cm), a width of 3.5 cm, and an unknown depth. The (MONTH) (YEAR) physician's orders [REDACTED].[MEDICATION NAME] Packing Strip 1 (inch) x (by) 5 yard bandage .one time daily .clean wound with NS (Normal Saline) pat dry, irrigate wound with (Named wound cleanser) and pack undermined area with [MEDICATION NAME] packing strips .cover with dressing daily . Observation in Resident #36's room on 5/8/18 at 1:45 PM, revealed Licensed Practical Nurse (LPN) #3 and LPN #5 performed a dressing change for Resident #36. LPN #3 applied the [MEDICATION NAME] packing strip outside the wound bed in a circle that could be seen outside the undermined area. LPN #3 did not follow physician's orders [REDACTED]. Interview with the Assistant Director of Nursing (ADON) on 5/9/18 at 9:50 AM in the conference room, the ADON was asked when using [MEDICATION NAME] gauze to pack an undermined wound bed what should it look like. The ADON stated, You should only be able to see a little tail on the outside.

Based on policy review, observation, and interview the facility failed to ensure medications were properly stored in 1 of 6 (equipment room) medication storage areas. The findings included: The facility's Medication and Biological Storage, Night/Emergency Box and Backup Pharmacy policy documented, .The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued .outdated .these medications are destroyed . Observation in the equipment room on 5/8/18 at 5:27 PM, revealed (32) 5 milliliter (ml) syringes of [MEDICATION NAME] with an expiration date of 1/12/17, (1) 1000 ml bag of 5 percent (%) [MEDICATION NAME] and 45% Sodium Chloride intravenous fluid with an expiration date of 8/1/17. Interview with Licensed Practical Nurse (LPN) #2 on 5/8/18 at 5:27 PM in the equipment room, LPN #2 confirmed the above medications were expired. Interview with the Director of Nursing (DON) on 5/8/18 at 5:32 PM in the DON's office, the DON was asked if it was acceptable to have expired medications in the equipment room. The DON stated, .No .it should be tossed .

Based on observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed during dining when 2 of 11 (Certified Nursing Assistant (CNA)# 3 and #5) staff members handled the inside of the plates and bowls. The findings included: Observation in the Dining Room on 5/7/18 beginning at 11:25 AM, revealed CNA #3 served lunch to the residents with her thumb inside the plates and bowls. Observation in the Dining Room on 5/8/18 beginning at 5:05 PM, revealed CNA #5 served dinner to the residents with her thumb inside the plates and bowls. Interview with the Administrator on 5/9/18 at 2:39 PM, in the Administrator's office, the Administrator was asked if it was appropriate for staff to place their thumbs inside the plates and bowls while serving the residents. The Administrator stated, No .

Based on Lippincott Manual of Nursing Practice 10TH EDITION, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed for the care of an indwelling urinary catheter for 1 of 3 (Resident #36) sampled residents reviewed with indwelling urinary catheters. The findings included: 1. The Lippincott Manual of Nursing Practice 10TH EDITION, page 782, documented, .Keep the drainage bag in a dependent position, below the level of the bladder . 2. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) physician's orders [REDACTED].promote wound healing . Observation in Resident #36's room on 5/8/18 at 1:50 PM, revealed Licensed Practical Nurse (LPN) #4 and Certified Nursing Assistant (CNA) #1 performed a linen change, held the catheter bag and tubing above the resident's abdomen allowing the urine to flow back into the tubing. Interview with the Director of Nursing (DON) on 5/9/18 at 9:31 AM in the conference room, the DON was asked if it was acceptable to raise an indwelling catheter above the bladder. The DON stated No.

Based on policy review, review of dish machine temperatures sanitation logs, observation, and interview, the facility failed to ensure foods were prepared, served, and stored under sanitary conditions as evidenced by foods not properly labeled with open and expiration dates, dirty vent, improper low temperature dish machine temperatures, 6 of 8 (Dishwasher #1, Dietary Manager, Cook #1 and 2, Dietary Aide #1 and 2) dietary staff had hair exposed while performing duties in the kitchen and preparing trays on the tray line, carbon build up on pans, and improper storage of bleach and oven jell, and 1 of 14 (Certified Nursing Assistant (CNA) #1) staff members failed to perform hand hygiene during dining observations. The facility had a census of 51, with 49 of those residents receiving a tray from the kitchen. The findings included: 1. The facility's DISHWASHING policy documented, .Procedure .Turn on machine, checking temperatures to assure proper wash and rinse temperatures for your machine .Low temp (temperature) machine .120-140 (sign for degrees) .Required Record .The temperature of the dish machine will be observed and recorded three .times a day .Low temperature machines should be between 120 (sign for degrees) - 140 (sign for degrees) F (Fahrenheit) .Any temperature recorded outside the acceptable levels should be reported to the supervisor immediately. Maintenance should be notified . The facility's STORAGE policy documented, .PERISHABLE FOOD ITEMS .Leftover food .They are covered, labeled and dated . Observations in the kitchen on 4/24/17 beginning at 9:10 AM revealed the following: a. The walk-in freezer had a clear plastic bag with 7 hamburger patties not labeled, dated and had no expiration date. Interview with the Dietary Manager on 4/24/17 at 9:15 AM, in the walk-in freezer, the Dietary Manager confirmed the bag of hamburger patties were not labeled or dated. b. The dry storage area had a dirty vent over the food stored on a shelf. Interview with the Dietary Manager on 4/24/17 at 9:18 AM, in the dry storage room, the Dietary Manager was asked if the vent was dirty. The Dietary Manager stated,They sure are c. The wash cycle on the low temperature dishwasher was performed by the Dietary Manger and was 102 degrees. The rinse cycle temperature was 101 degrees. d. Review of the DISH MACHINE TEMPERATURES-SANITATION log revealed for the month of January, February, March, and April 1 to April 23, 2017 revealed the wash and rinse cycle temperatures were between 90 to 110 degrees. Interview with the Dietary Manager on 3/24/17 at 9:25 AM, in the dish room, the Dietary Manager was asked what the expected temperature of the wash and rinse cycle should be. The Dietary Manager stated, Between 80 to 100 . Interview with the Dietary Manager on 4/25/17 at 5:17 PM, in the kitchen, the Dietary Manager was asked what she would expect the wash cycle on the low temperature machine to be. The Dietary Manager stated, It should be 120 to 145. The Dietary Manager was asked what she would expect the rinse cycle on the low temperature machine to be. The Dietary Manager stated, 120 or above. The Dietary Manager was asked if the wash and rinse cycle were at the proper temperature on the low temperature dishwasher. The Dietary Manager stated, Have not been in the past . d. Dishwasher #1 and Cook #1 had hair not completely covered with a hair restraint. e. A bin of sugar, flour and meal were not dated. Interview with the Dietary Manager on 4/24/17 at 9:30 AM, in the kitchen, the Dietary Manager confirmed there was no date on the bins of sugar, flour and meal. 3. Observations in the kitchen on 4/24/17 beginning at 4:40 PM, revealed the Dietary Manager, Cook #2 and #3 had hair not completely covered with a hair restraint . 4. Observations in the kitchen on 4/25/16 beginning at 4:45 PM revealed the following: a. The Dietary Manager, Cook #2, Dietary Aide #1 and #2 had hair not completely covered by hair restraint while preparing trays on the tray line and performing duties in the kitchen. b. Carbon build up on a large and medium sauce pan. Interview with the Dietary Manager on 4/25/17 at 4:50 PM, in the kitchen, the Dietary Manager was asked what was on the pans. The Dietary Manger stated, There's carbon on that . c. 1 gallon of bleach and a container of Oven jell was sitting on the shelf next to the 3 compartment sink. Interview with the Dietary Manger on 4/25/17 at 4:53 PM, in the kitchen, the Dietary Manager was asked if the bleach and oven jell should be stored beside the 3 shelf by the 3 compartment sink. The Dietary Manager stated, No, it should not d. Carbon build up on the butter pan sitting on the stove. Interview with the Dietary Manager on 4/25/17, at 4:55 PM, besides the stove in the kitchen, the Dietary Manager stated, There is carbon there also. e. 1 large container of vanilla flavoring had no open date. Interview with the Dietary Manager on 4/25/17 at 5:10 PM, in the dry storage area, the Dietary Manager was asked if there was an opened date on the Vanilla flavoring. The Dietary Manger stated, It doesn't have an open date. Interview with the Dietary Manger on 4/26/17 at 1:25 PM, in the Dietary Manager office, the Dietary Manager was asked would you expect hair to be completely covered when in the kitchen. The Dietary Manager stated, Yes, at all time in the kitchen and shook her head yes. 5. The facility's Hand Hygiene policy documented, .Hand hygiene is the simplest, most effective means of infection control .Hand hygiene must be performed at a minimum .Before and after each patient contact .Before donning gloves and after removing gloves . Observations in Resident #17's room on 4/24/17 at 11:37 AM, revealed CNA #1 assisted Resident #17 to sit up in her recliner, positioned Resident #17's feet and moved the overbed table close to the resident. CNA #1 then set up Resident #17's food tray and prepared her food for her to eat, touching the silverware and the straw without performing hand hygiene. Interview with the Assistant Director of Nursing (ADON) in the conference room on 4/26/17 at 10:10 AM, the ADON was asked what she expected staff to do before preparing and serving a meal for a resident. The ADON stated, Wash their hands. The ADON was asked whether it was acceptable for the staff to touch the resident's feet and then set up the meal without performing hand hygiene. The ADON stated, No.

Based on policy review, medical record review, observation, and interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to have an effective ongoing quality program that identified, developed, implemented and monitored appropriate plans of action to correct issues. The findings included: 1. The QAA Committee failed to ensure residents were accurately assessed to reflect their current status. Refer to F 278. The deficient practice of F 278 is a repeat deficient practice for failure to accurately assess the resident to reflect the resident's status. The facility was cited on this recertification survey and on 1/20/15 and 2/18/16. 2. The QAA Committee failed to ensure food was stored, prepared, distributed and served under sanitary conditions related to dining and kitchen sanitation. Refer to F 371 The deficient practice of F 371 is a repeat deficient practice to ensure food was stored, prepared, distributed and served under sanitary conditions. The facility was cited F 371 on this recertification survey and on 7/20/12, 1/20/15, and 2/15/16. Interview with the Administrator and the Assistant Director of Nursing (ADON) on 4/26/17 at 2:03 PM, in the Administrator's office, the Administrator and ADON was asked about the quality assurance issues. The Administrator stated We are auditing the accuracy of assessments, we are training a second MDS person .We submit our assessments to Point Right for accuracy . The Administrator stated . kitchen sanitation we are cleaning the pots and pans from carbon build up frequently . The ADON stated . we have inservices on hand hygiene .when and where to do it. It is a constant reminder .We do demonstrations and check them off . The Administrator and the ADON were asked if they feel they have an effective QAA committee. The Administrator and the ADON stated Yes.

Based on policy review, medical record review, observation and interview, the facility failed to ensure privacy was maintained when 1 of 3 (Licensed Practical Nurse (LPN) #2) nurses administered medications to a resident via a Percutaneous Endoscopic Gastrostomy (PEG) tube while the window blind was open, exposing the resident's abdominal area. The findings included: 1. The facility's Resident Rights policy documented, .Employees must treat all patients with the kindness, respect and dignity .LISTING OF RESIDENT RIGHTS .To privacy in treatment and personal care . 2. Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #100's room on 4/25/17 at 11:21 AM, revealed LPN #2 pulled back the bed linens exposing Resident #100's abdomen, and administered water and medications through the PEG tube while the window blind was left open to the parking lot outside. Interview with the Assistant Director of Nursing (ADON) on 4/26/17 at 10:10 AM, in the conference room, the ADON was asked whether it was acceptable for the window blind to be left open during medication administration through a PEG tube. The ADON stated, No.

Based on policy review, medical record review, observation, and interview, the facility failed to provide care in a manner that promoted the residents' dignity when 1 of 3 (Licensed Practical Nurse (LPN) #2) nurses failed to knock or gain permission to enter before entering a resident's room during medication administration. The findings included: 1. The facility's Resident Rights policy documented, .Employees must treat all patients with the kindness, respect and dignity .LISTING OF RESIDENT RIGHTS .To privacy in treatment and personal care . 2. Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #100's room on 4/25/17 at 11:21 AM, revealed LPN #2 entered the room without knocking. Interview with the Assistant Director of Nursing (ADON) on 4/26/17 at 10:10 AM, in the conference room, the ADON was asked what she expected staff to do before entering a resident room. The ADON stated, Knock on the door and address themselves.

Based on medical record review and interview, the facility failed to properly assess residents for incontinence, medication use, and dental problems for 4 of 15 (Residents #19, 23, 32 and 47) sampled residents reviewed of the 21 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5 day/Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented Resident #19 was frequently incontinent of urine (7 or more episodes of incontinence) and always continent of bowel during the 7 day look back period. The ADL (Activities of Daily Living) Verification Worksheet for November 2016 documented Resident #19 was incontinent of bladder on 5 days (11/22, 11/23, 11/26, 11/27 and 11/28) and incontinent of bowel on 2 days (11/22 and 11/28) during the MDS look back period of 11/22/16 through 11/28/16. The Clinical Notes Report dated 11/22/16 through 11/28/16 documented Resident #19 was incontinent of bowel and bladder on 11/22/16, 11/24/16, 11/26/16, and 11/28/16. Interview with the MDS Coordinator on 4/26/17 at 12:35 PM, in the MDS office, the MDS Coordinator was asked how she determined the resident was continent or incontinent when coding the MDS. The MDS Coordinator stated that she talks to staff, reads nurses' notes and talks to the resident if they are alert. The MDS Coordinator was asked if she refers to the ADL Verification Worksheet. The MDS Coordinator stated, .not really . The MDS Coordinator looked at the nurses' notes for 11/22/16 through 11/28/16. The MDS Coordinator was asked if the MDS for 11/28/16 was coded correctly for continence. The MDS Coordinator stated Apparently not . 2. Medical record review revealed Resident #23 was admitted to facility on 10/7/05 with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] documented Resident #23 received an anticoagulant medication on 7 of 7 days of the look back period. The April 2017 physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. Interview with the MDS Coordinator on 4/25/17 at 3:39 PM, in the MDS office, the MDS Coordinator was asked if the 3/7/17 MDS was coded correctly for anticoagulant medications. The MDS Coordinator stated, .[MEDICATION NAME] .it's a blood thinner . The MDS Coordinator was asked to look in the Resident Assessment Instrument (RAI) manual to see if antiplatelet medications should be coded on the MDS. The MDS Coordinator stated, .I guess you were right (indicating that antiplatelet medications are not coded on the MDS as anticoagulants) . 3. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE] documented Resident #32 received no Insulin injections during the 7 day look back period. The MAR for August 2016, September 2016, February 2017, and March 2017 documented Resident #32 received the insulin daily. The admission MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE] documented Resident #32 received insulin no days of the 7 day look period. Interview with the MDS Coordinator on 4/26/17 at 8:05 AM, in the MDS office, the MDS Coordinator was asked if Resident #32 was receiving insulin during the 7 day look back period and if the MDS was correct for the admission MDS dated [DATE] and the quarterly MDS dated [DATE]. The MDS Coordinator stated No, It is not correct .Apparently I thought she was not a diabetic. 4. Medical record review revealed Resident #47 was admitted to facility on 3/6/14 with [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] documented Resident #47 had no dental problems. Observations in Resident #47's room on 4/24/2017 at 1:53 PM, revealed Resident #47 lying in bed with broken teeth noted. Interview with the MDS Coordinator, on 4/26/17 at 9:35 AM, in the MDS office, the MDS Coordinator was asked if the significant change MDS was coded correctly for dental problems. The MDS Coordinator stated, No, that is incorrect .

Based on policy review, review of the GERIATRIC MEDICATION HANDBOOK ELEVENTH EDITION, medical record review, observation, and interview the facility failed to ensure 1 of 3 (Licensed Practical Nurse (LPN) #1) nurses administered medications accurately with a medication error rate of less than 5 percent (%). A total of 3 medication errors were observed out of 32 possible opportunities, resulting in a medication error rate of 9.375%. The findings included: 1. The facility's Director of Nursing Training Manual policy documented, .Metered Dose Inhalers .If more than one puff is required (the same medication or a different medication), the clinician should follow the manufacturer's product information for administration instructions .allow acceptable wait time between inhalations . 2. The facility's Nasal Spray Administration Procedure for Adults policy documented, .Wash hands .Spray firmly and quickly .Rinse the outside of the container with hot water and dry with a clean tissue .Replace bottle cap .Wash hands . 3. The GERIATRIC MEDICATION HANDBOOK ELEVENTH EDITION documented, .Inhaled Medications .If another puff of the same or different medication is required, wait 1-2 minutes .NASAL MEDICATION ADMINISTRATION .If another dose of the same or different nasal medication is required in the same nostril, wait the amount of time recommended by the manufacturer . 4. Medial record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] 160 mcg (micrograms)-4.5 mcg/actuation .2 puffs .BID (twice daily) .[MEDICATION NAME] 50 mcg/actuation nasal spray .2 sprays .Both Nostrils .once daily .[MEDICATION NAME] with HandiHaler 18 mcg .inhalation once daily . Observations in Resident #5's room on 4/25/17 at 8:08 AM, revealed LPN #1 administered [MEDICATION NAME] nasal spray, 2 consecutive sprays to each of Resident #5's nostrils, resulting in medication error #1. LPN #1 then immediately administered [MEDICATION NAME] 2 consecutive inhalations to Resident #5, one immediately following the other. This resulted in medication error #2. LPN #1 then immediately administered [MEDICATION NAME] 1 inhalation, without waiting atleast 1 minute. This resulted in medication error #3. Interview with the Assistant Director of Nursing (ADON) on 4/26/17 at 10:10 AM, in the conference room, the ADON was asked how long should the nurse wait between nasal sprays in the same nare. The ADON stated, 1-2 minutes. The ADON was asked how long nursing staff should wait between inhalations of the same medication. The ADON stated, According to the manufacturer's guidelines. The ADON was asked how about between inhalations of different medications. The ADON stated, I think with steroids it's about 5 minutes .

Based on policy review, observation, and interview the facility failed to ensure the prevention of the potential spread of infection when 1 of 3 (Licensed Practical Nurse (LPN) #1) nurses failed to perform hand hygiene and failed to cleanse the tip of the nasal spray after use during medication administration. The findings included: 1. The facility's Hand Hygiene policy documented, .Hand hygiene is the simplest, most effective means of infection control .Hand hygiene must be performed at a minimum .Before and after each patient contact .Before donning gloves and after removing gloves . 2. The facility's Nasal Spray Administration Procedure for Adults policy documented, .Wash hands .Spray firmly and quickly .Rinse the outside of the container with hot water and dry with a clean tissue .Replace bottle cap .Wash hands . 3. Observations in Resident #5's room on 4/25/17 at 8:08 AM, revealed LPN #1 administered [MEDICATION NAME] nasal spray, 2 consecutive sprays to each of Resident #5's nostrils, then immediately administered [MEDICATION NAME] and [MEDICATION NAME] inhalations. LPN #1 did not perform hand hygiene after administering the nasal spray. LPN #1 replaced the cap on the nasal spray after use without cleaning the tip. Interview with the Assistant Director of Nursing (ADON) on 4/26/17 at 10:35 AM, in the conference room, the ADON was asked whether she expected staff to wash their hands after administering nasal spray to a resident. The ADON stated, Yes.

Based on policy review, medical record review, and interview the facility failed to ensure the medical record was complete and accurate for 1 of 15 (Resident #50) sampled residents of the 21 residents included in the stage 2 review. The findings included: 1. The PRESSURE ULCER DOCUMENTATION policy documented, .The Date of Onset and the Location must be documented . 2. Medical record review revealed Resident #50 was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. The WOUND AND PRESSURE ULCER INFORMATION form dated 1/28/17 did not document the nurse's signature that completed the form. The WOUND AND PRESSURE ULCER INFORMATION forms dated 1/28/17 and 1/29/17 documented a pressure ulcer to the right inner heel with an onset date of 1/28/17 and facility acquired. The WOUND AND PRESSURE ULCER INFORMATION forms dated 2/17/17, 2/20/17, 2/28/17, 3/5/17, 3/13/17, 3/26/17, 4/3/17, 4/9/17, 4/20/17, and 4/23/17 did not document the onset date and documented the pressure ulcer developed prior to admission. The WOUND AND PRESSURE ULCER INFORMATION form dated 2/20/17 did not document the tissue type of the wound. Interview with the Assistant Director of Nursing on 4/25/17 at 3:20 PM, in the Assistant Director of Nursing (ADON) office, the ADON was asked if she would expect the Wound and Pressure Ulcer Information form to document the tissue type. The ADON stated, Yes. The ADON was asked would you expect the onset date to be documented on the Wound and Pressure Ulcer Information form. The ADON stated, Yes. On 4/26/17 at 10:10 AM, in the conference room, the ADON stated the pressure was facility acquired and not acquired prior to admission.

Based on medical record review and interview, the facility failed to revise the care plan for bowel incontinence and medication use for 2 of 15 (Resident #19 and #23) sampled residents reviewed of the 21 residents included in the Stage 2 review. The findings included: 1. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The ADL (Activities of Daily Living) Verification Worksheet for November 2016 documented that Resident #19 was incontinent of bowel 8 times during that month. The nurses' notes for 11/22/16 through 11/28/16 documented Resident #19 was incontinent of bowel and bladder 4 times during that time period. The care plan dated 11/30/16 documented .Continent of bowel . Interview with the MinimumData Set (MDS) Coordinator on 4/26/17 at 12:35 PM, in the MDS office, the MDS Coordinator was asked if the care plan should have been updated to reflect bowel incontinence. The MDS Coordinator stated, Honestly, I think this (pointing to the care plan) is correct. The MDS Coordinator was asked if the nurses' notes and ADL worksheet were incorrect. The MDS Coordinator stated, The care plan should have been updated. 2. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The April 2017 physician's orders [REDACTED]. There was no order for a diuretic medication. The March 2017 Medication Administration Record [REDACTED]. The care plan dated 9/25/14 stated, .receiving diuretics on a regular basis .at risk for bleeding due to anticoagulant therapy .receiving antianxiety drugs on a regular and prn basis . Interview with the MDS Coordinator on 4/25/17 at 3:39 PM, in the MDS office, the MDS Coordinator was asked if Resident #19 received an anticoagulant medication. The MDS Coordinator stated, .[MEDICATION NAME] .it's a blood thinner . The MDS Coordinator was asked if the resident was receiving diuretics and antianxiety medications on a regular basis as indicated on the care plan. The MDS Coordinator stated .No .